Handbook of LGBT Elders
Debra A. Harley
Pamela B. Teaster Editors
An Interdisciplinary Approach to
Principles, Practices, and Policies
Handbook of LGBT Elders
Debra A. Harley Pamela B. Teaster
Editors
Handbook of LGBT Elders
An Interdisciplinary Approach
to Principles, Practices, and Policies
123
Debra A. Harley University of Kentucky Lexington, KY USA
Pamela B. Teaster Virginia Tech Blacksburg, VA USA
ISBN 978-3-319-03622-9 ISBN 978-3-319-03623-6 (eBook) DOI 10.1007/978-3-319-03623-6
Library of Congress Control Number: 2015943054 Springer Cham Heidelberg New York Dordrecht London
©Springer International Publishing Switzerland 2016
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.
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Every so often, a book comes along that substantially contributes to much-needed broader and deeper understanding of a minority group and to clarifying and addressing multiple pressing questions of social justice regarding that group. This is one of those books.
Contributing editors, Debra A. Harley and Pamela B. Teaster, have cre- ated a collection of all new essays on LGBT persons and aging that easily moves among elucidating the sometimes fluid boundaries of LGBT com- munities and individuals within those communities, to explanations and applications of basic principles ranging from queer theory to moral theory in addressing the issues facing LGBT persons and aging. And this is all done with an unblinking transnational eye. The collection’s reach is, in fact, a model for transnational studies including, as it does, discussions of LGBT persons and politics the worldwide, with special attention to aging.
The collection is rightly titled as a handbook, put together expressly for those who work with LGBT persons and policy in a variety of human ser- vices, including social work, physical and mental health care, the military and criminal justice systems, and education. But its reach is even farther than that. Anyone at all interested in the social positionality of LGBT persons will be well served by reading the essays gathered here.
Beginning with a clarification of who LGBT elders are and how being sexual/gender minorities influence social relationships from the most public to the most private, the collection moves through the complicated world of multiple identities, including race, age, health status, and how the intersec- tions of these identities often subject LGBT persons to multiple forms of oppression and exclusion. For example, in the contemporary USA, class, race, age, sexual orientation, and gender identity and presentation bestow privileges on some (namely, the middle and upper economic classes, Cau- casians, the young, heterosexuals, and those whose gender identity and presentation matches their “given” sex), and oppression and exclusion on others (namely, the poor, nonwhites, the elderly, gay men, and lesbian women, and trans persons). Every individual has multiple identities, and with those identities in a given society come benefits and burdens, many unique to certain identity combinations. So, for example, the life experiences of a white, middle class, lesbian elder will be importantly different from those of an African American, poor, transgender elder. This book takes such differ- ences very seriously.
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The collection also takes very seriously the reality that in so many areas, discrimination according to these categories is even firmly protected by law—laws that not just allow, but actually promote, discrimination in housing, employment, and public accommodation. And even if not formally protected by law, customary exclusions on the basis of biases such as racism, classism, ageism, homophobia, and transphobia continue to thrive as this book goes to press in 2015, which is likely to be the year when, according to the US Supreme Court, marriage equality (the legal recognition of same-sex marriages) becomes the law of the land. The contributing authors of this collection know well that if/when that happens, homophobia will not go away. Indeed, as this decision by the US Supreme Court comes to seem inevitable, there is a“frontlash”taking place as more and more US munic- ipalities introduce laws that will allow frank exclusion of sexual and gender minorities specifically on the basis of religious belief. So, even if marriage equality comes into the legal light as this book goes to press, the need for this unique collection will remain compelling.
By getting to the heart and effects of bias against sexual and gender minorities and their multiple identities as aged persons, this book makes an enormous and exquisitely timely contribution, not just to the empirical, theoretical, and practical literatures for service professionals, but to the lit- eratures on social justice, as well. We are all well served by it.
Joan Callahan Professor Emerita Department of Philosophy Department of Gender and Women’s Studies University of Kentucky
As editors of this text, Pamela and I have over 40 years of combined experience in service delivery; education; and research in aging, human rights, disability, and social services. Beginning in 2013, we collaborated on a chapter, Aging and Mistreatment: Victimization of Older Adults in the United States, and as part of that chapter, we wrote about LGBT elders.
Afterward, we discussed the lack of focus and collaboration across disci- plines in addressing LGBT elders. Although discipline-specific books have been published about LGBT populations, aging, health care, and human and social service, we decided that the time had come for a comprehensive text that addressed the challenges faced by LGBT elders. Our goal for this book is to discuss both LGBT elders who are from groups for which research was conducted often and groups rarely included in mainstream research (e.g., racial and ethnic groups, persons living in rural and remote areas, veterans, [ex]-offender populations, immigrants, and persons with disabilities). In addition, we decided to cover issues that impact LGBT persons individually and collectively. Our 36 chapters cover the following topics pertaining to LGBT elders: theories and constructs, the nexus of sexual minority status and aging, family relationships, deconstruction of“isms,”African American and Blacks, American Indians, Asian and Pacific Islanders, Europeans, Hispan- ics, veterans, [ex]-offenders, immigrants, transgendered persons, bisexual persons, mistreatment and victimization, bullying, healthcare reform and healthcare practices, residents of long-term care facilities, end-of-life issues, mental health, substance abuse, the impending US Supreme Court ruling on same-sex marriage, ethics and ethical standards, law enforcement and public safety, religious and faith communities, workplace issues, counseling, socialization and recreation, advocacy, disability, and trends and future directions. Our comprehensive handbook recognizes the intersection of identities because individuals do not exist or live their lives in separate compartments.
At the writing of this text (March 2015), we are awaiting the outcome of the Supreme Court ruling on same-sex marriage. The ruling has significant implications for LGBT elders in many areas of their lives, including housing, health insurance and benefits, medical decisions, and the definition of family and spouse. The timing of the ruling may shed a different perspective on the information presented in some of the chapters.
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Our text provides an interdisciplinary perspective on LGBT elders.
A unique feature is that the authors of the individual chapters represent an array of diverse backgrounds and expertise. Among the disciplinary per- spectives represented are social work, public health, medicine, rehabilitation counseling, law, public policy, counseling, diversity consultation, gerontol- ogy, psychiatry, and education. The broad assemblage of disciplines is important in adequately addressing challenges, resiliency, and strengths of LGBT eldersvis a visan interdisciplinary perspective. Many of the chapters also include international perspectives about LGBT elders, populations, and cultures.
We do not present this text as inclusive of all aspects that impact LGBT elders, but rather, we hope that it will be an important contribution to the existing literature as well as a response to identified gaps in policy, practice, and research. Although texts on services and programs assisting older adults are readily available, they focus primarily on the general population and rarely if ever take into account the unique circumstances facing current and future LGBT elders. Our desire is for the text to serve as a useful and reliable resource for those studying and teaching for those involved in health care, human and social services programs, as well as in courses on diversity and gender and women’s studies. Similarly, practitioners, policy and decision makers, advocates, community leaders, families, and LGBT elders them- selves may benefit from this text.
Debra A. Harley Pamela B. Teaster
Part I Foundations of Aging and Sexual Identities 1 Theories, Constructs, and Applications in Working
with LGBT Elders in Human Services. . . 3 Debra A. Harley and Pamela B. Teaster
2 Sexual Minority Status and Aging. . . 27 Pamela B. Teaster, John T. White and Sujee Kim
3 Family Relationships of Older LGBT Adults. . . 43 Katherine R. Allen and Karen A. Roberto
4 Deconstructing Multiple Oppressions Among
LGBT Older Adults . . . 65 Tracy Robinson-Wood and Amanda Weber
5 The Intersection of Identities of LGBT Elders:
Race, Age, Sexuality, and Care Network . . . 83 Melanie D. Otis and Debra A. Harley
Part II Multicultural, International, and Select Populations of LGBT Elders
6 African-American and Black LGBT Elders. . . 105 Debra A. Harley
7 American Indian, Alaska Native, and Canadian
Aboriginal Two-Spirit/LGBT Elderly. . . 135 Debra A. Harley and Reginald J. Alston
8 Asian American and Native Pacific Islander
LGBT Elders. . . 159 Debra A. Harley
9 European LGBT Elders . . . 177 Melanie D. Otis
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10 Hispanic/Latino LGBT Elders. . . 199 Debra A. Harley
11 Elder LGBT Veterans and Service Members. . . 223 Thomas W. Miller
12 LGBT Elders and the Criminal Justice System . . . 239 Tina Maschi, Jo Rees, Eileen Klein and Ron Levine
13 Immigrant LGBT Elders. . . 261 Amanda E. Sokan and Tracy Davis
14 Understanding Transgender Elders. . . 285 Loree Cook-Daniels
15 Bisexuality: An Invisible Community Among
LGBT Elders. . . 309 William E. Burleson
Part III Mistreatment and Victimization of Older LGBT Persons
16 An Overview of Aging and Mistreatment
of LGBT Elders. . . 325 Amanda E. Sokan and Pamela B. Teaster
17 Mistreatment and Victimization of LGBT Elders. . . 343 Pamela B. Teaster and Amanda E. Sokan
18 The Prevalence of Elder Bullying and Impact
on LGBT Elders. . . 359 Robin P. Bonifas
Part IV Health Care and Mental Health
19 Impact of Healthcare Reform on LGBT Elders . . . 375 Debra A. Harley
20 Healthcare, Sexual Practices, and Cultural Competence
with LGBT Elders . . . 391 Tracy Davis and Amanda E. Sokan
21 LGBT Elders in Nursing Homes, Long-Term Care
Facilities, and Residential Communities. . . 417 John T. White and Tracey L. Gendron
22 End-of-Life Issues for LGBT Elders . . . 439 David Godfrey
23 Mental Health Counseling of LGBT Elders. . . 455 Tracey L. Gendron, Terrie Pendleton and John T. White
24 Substance Use Disorders Intervention
with LGBT Elders . . . 473 Debra A. Harley and Michael T. Hancock
Part V Family and Community
25 LBGT Elders in Rural Settings, Small Towns,
and Frontier Regions . . . 493 Debra A. Harley
26 Law Enforcement and Public Safety of LGBT Elders. . . 513 Randy Thomas
27 The Role of Religious and Faith Communities
in Addressing the Needs of LGBT Elders. . . 525 Debra A. Harley
28 No Money, No Work, and You’re Old. . . 545 Brian McNaught
29 LGBT Intersection of Age and Sexual Identity
in the Workplace . . . 551 Debra A. Harley and Pamela B. Teaster
30 Isolation, Socialization, Recreation, and Inclusion
of LGBT Elders. . . 563 Debra A. Harley, Linda Gassaway and Lisa Dunkley
Part VI Counseling and Human Services Delivery
31 Counseling LGBT Elders . . . 585 Steven D. Johnson and Anthony Fluty Jr.
32 Advocacy and Community Needs Assessment. . . 601 Robert Espinoza
33 Disabilities and Chronic Illness Among LGBT Elders:
Responses of Medicine, Public Health, Rehabilitation,
and Social Work. . . 619 Debra A. Harley
Part VII Conclusion
34 Ethical Standards and Practices in Human Services
and Health Care for LGBT Elders . . . 639 Pamela B. Teaster and Amanda E. Sokan
35 Trends, Implications, and Future Directions for Policy,
Practice, and Research on LGBT Elders . . . 657 Pamela B. Teaster and Debra A. Harley
36 Implications of DOMA and the Supreme Court Ruling
on Same-Sex Marriage for Spousal Benefits. . . 671 Debra A. Harley and Pamela B. Teaster
Glossary. . . 685 Index . . . 689
About the Editors
Debra A. Harley, Ph.D., CRC, LPC is a professor in the Department of Early Childhood, Special Education, and Rehabilitation Counseling at the University of Kentucky (UK). Professor Harley holds the distinction of Provost’s Distinguished Service Professor. She is past editor of the Journal of Rehabilitation Counseling and the Journal of Rehabilitation Administration and guest editor of numerous special issues of rehabilitation journals. She is co-editor of a book, Contemporary Mental Health Issues Among African Americans. Professor Harley has published over 80 refereed articles and 26 book chapters. She has served on the certification board for rehabilitation counselors, the Certified Rehabilitation Counselor Commission, and the accreditation board rehabilitation counselor education programs, Council on Rehabilitation Education. Professor Harley is affiliate faculty with the Department of Gender and Women’s Studies, the Center Research on Research on Violence Against Women, and the Human Development Institute at UK. She has received the Educator of the Year Award by the National Council on Rehabilitation Education and the Provost’s Award for Outstanding Teaching by the University of Kentucky. Professor Harley’s primary teaching assignment at UK is in rehabilitation counseling, in which she teaches courses and does research in the areas of cultural diversity, gender issues, and substance abuse.
Pamela B. Teaster is the associate director for Research at the Center for Gerontology and a professor in the Department of Human Development at Virginia Tech. She established the Kentucky Justice Center for Elders and Vulnerable Adults and the Kentucky Guardianship Association and was its first president. She is the secretary general of the International Network for the Prevention of Elder Abuse. She served as director and chairperson of the Graduate Center for Gerontology/Department of Gerontology as well as the director of Doctoral Studies and associate dean for Research for College of Public Health at the University of Kentucky. She serves on the editorial board of theJournal of Elder Abuse and NeglectandFrontiers.Dr. Teaster is
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a fellow of the Gerontological Society of America and the Association for Gerontology in Higher Education, a recipient of the Rosalie Wolf Award for Research on Elder Abuse, the Outstanding Affiliate Member Award (Kentucky Guardianship Association), and the Distinguished Educator Award (Kentucky Association for Gerontology). She has served as both board member and president of the National Committee for the Prevention of Elder Abuse. She has received funding from The Retirement Research Foundation, Administration on Aging, National Institute on Aging, Kentucky Cabinet for Families and Children, National Institute of Justice, Centers for Disease Control, National Institute of Occupational Safety and Health, Health Resources and Services Administration, and the Office of Victims of Crime.
Her areas of scholarship include the mistreatment of elders and vulnerable adults, public and private guardianship, end-of-life issues and decision making, ethical treatment of vulnerable adults, human rights issues for vulnerable adults, public policy and public affairs, public health ethics, and quality of life. She is the co-author of two books and of over 100 peer-reviewed articles, reports, and book chapters.
Contributors
Katherine R. Allen is professor of Human Development at Virginia Tech, and a faculty affiliate of the Center for Gerontology, Faculty of Health Sciences, and the Women’s and Gender Studies Program. She is a fellow of the Gerontological Society of America and the National Council on Family Relations. Her research involves the study of family diversity over the life course, family experiences of LGBT adults, feminist family studies, and sexuality in adulthood.
Reginald J. Alston, Ph.D., CRC, NCC is a professor and associate chancellor at the University of Illinois, Urbana-Champaign.
Robin P. Bonifas, Ph.D. is an associate professor at the Arizona State University School of Social Work. She has over 15 years of experience working with elders and their families in both long-term care and inpatient psychiatric settings. Her research focuses on enhancing psychosocial care for persons with chronic illness and disability, especially those with comorbid mental health conditions and those requiring long-term care. Her current projects examine elder social justice issues such as resident-to-resident aggression in nursing homes, late-life bullying, and other challenges to social relationships in senior care organizations.
William E. Burleson is the author of Bi America: Myths, Truths, and Struggles of an Invisible Community (Rutledge 2005), a book about the bisexual community and the bisexual experience. Burleson’s work has appeared in the Lambda Book Report, the Journal of Bisexuality, and various print and online LGBT publications, and he has been a speaker at college campuses across the country (www.williamburleson.com).
Loree Cook-Daniels has been working on LGBT aging issues for more than four decades, focusing particularly on public policy and social change. She is the founder of the Transgender Aging Network and currently serves as policy and program director for FORGE, Inc.
Tracy Davis is an assistant professor at Rutgers University, School of Health Related Professions in the Department of Interdisciplinary Studies.
She holds a Ph.D. from the University of Kentucky in gerontology. Her research interests include LGBT aging, HIV/AIDS and aging, health pro- motion, and disease prevention.
Lisa Dunkley, M.A., CRCis a doctoral student in Rehabilitation Counseling Program at the University of Kentucky.
Robert Espinoza is vice president of policy at Paraprofessional Healthcare Institute, a national organization focused on transforming eldercare and disability services by improving the lives of direct care workers—nearly 4 million home health aides, certified nurse aides, and personal care attendants.
Espinoza currently serves on advisory boards for Story Corps, the Johns Hopkins School of Medicine, and Aging Today, the national newspaper for the American Society on Aging.
Anthony Fluty Jr., MSW, LCSWis a substance abuse counselor at Eastern State Hospital in Lexington, Kentucky. He has also had clinical experience working with senior adults in an intensive outpatient program conducting group psychotherapy.
Linda Gassaway, Ed.Dis a lecturer in the Department of Early Childhood, Special Education, and Rehabilitation Counseling at the University of Kentucky.
Tracey L. Gendron is an assistant professor with the Department of Gerontology in the School of Allied Health Professions at Virginia Com- monwealth University. Tracey has a Master of Science in gerontology, a Master of Science in psychology and a Ph.D. in developmental psychology.
She teaches several graduate and undergraduate service-based courses including grant writing, research methods, and old is the new young. She is also a Service-Learning faculty fellow at Virginia Commonwealth Univer- sity. Tracey takes an all-inclusive approach to teaching about aging, partic- ularly highlighting those understudied and underrepresented groups that are at increased risk of negative health outcomes and discrimination. Her community-engaged research interests include the professional identity development and career commitment of gerontologists, education through community engagement and service-learning, aging anxiety, ageism and gerontophobia, LGBT aging and staff knowledge and quality of care.
David Godfrey, J.D.is a senior attorney to the ABA Commission on Law and Aging in Washington DC. He is responsible for the ABA’s role in the Administration on Aging funded National Legal Resource Center and for
producing the National Aging and Law Conference. He is a board member of the National Academy of Elder Law Attorneys. Prior to joining the Commission, he was responsible for elder law programming at Access to Justice Foundation in Kentucky.
Michael T. Hancock, M.A. is a doctoral student in the Rehabilitation Counseling Program at the University of Kentucky.
Steven D. Johnson, Ph.D., LCSW is vice-chair of Education for the Department of Psychiatry at the University of Kentucky. He works exten- sively with LGBTQ clients as well as teaching and supervising psychiatry residents in their psychotherapy training.
Sujee Kim is a doctoral student in the Adult Development and Aging Program at Virginia Tech. Her research interests include long-term care- giving and productive aging.
Eileen Klein, Ph.D. is an assistant professor at the Ramapo College Department of Social Work. Her research interests LGBT persons with serious mental health issues and culturally responsive and LGBT affirming treatment.
Ron Levine is a professional photographer and documentary maker. He is known for his Prisoners of Age photo exhibit.
Tina Maschi, Ph.D., LCSW, ACSW is an associate professor at the Fordham University Graduate School of Social Service with research inter- ests at the intersection of trauma, mental health, and aging, especially related to vulnerable elders in the criminal justice system. She is the founder and president of Be the Evidence International:www.betheevidence.org.
Brian McNaught was named “the godfather of gay diversity training”by The New York Times. He has been brought to offices throughout the world to help managers create welcoming environments for LGBT employees. He is the author of several books and is featured in numerous DVDs on LGBT issues. He and his spouse, Ray Struble, have been together since 1976.
Thomas W. Miller, Ph.D., ABPP is professor emeritus, senior research scientist, master teacher, great teacher and university teaching fellow during forty-year tenure at the University of Kentucky College of Medicine, Uni- versity of Connecticut, School of Allied Health, and Murray State University.
Tenured in the Department of Psychiatry, he held joint appointments in the Department of Psychology, College of Arts and Sciences and the Department of Educational, School and Counseling Psychology, College of Education, University of Kentucky. He served as a career VA chief psychology service and developed the first APA-approved Psychology Internship in the Com- monwealth of Kentucky. He received his doctorate from the State University of New York, is a diplomate of the American Board of Professional Psy- chology in Clinical Psychology, fellow of the American Psychological
Association, the Association of Psychological Science and the Royal Society of Medicine. He is editor and author of the Praeger Handbook on Veterans Health.
Melanie D. Otis, Ph.D.is the Richard K. Brautigam Professor of Criminal, Juvenile, and Social Justice in the College of Social Work at the University of Kentucky. Dr. Otis has served as editor-in-chief of the Journal of Gay and Lesbian Social Services since 2010.
Terrie Pendleton is a Licensed Clinical Social Worker (LCSW) in Rich- mond, Virginia. She received her master’s degree in social work from Vir- ginia Commonwealth University. Ms. Pendleton has held positions as an adjunct instructor and faculty field liaison with Virginia Commonwealth University, School of Social Work. She has served as a Steering Committee Member for the organization, Services and Advocacy for Gay, Lesbian, and Bisexual & Transgender Elders (SAGE) in Richmond VA and has provided clinical counseling and support to the LGBT community. Terrie lives happily with her partner of 22 years and their two dogs.
Jo Rees, Ph.D.is an assistant professor on Long Island University Depart- ment of Social Work. Her research interests lie at the intersection of LGBT issues, mental health, and the criminal justice system.
Karen A. Roberto is professor and director of the Center for Gerontology and the Institute for Society, Culture and Environment at Virginia Tech, and a faculty member in Human Development, the Faculty of Health Sciences, and in the Departments of Internal Medicine and Psychiatry and Behavioral Medicine at the Virginia Tech Carilion School of Medicine. She is a fellow of the American Psychological Association, the Gerontological Society of America, and the National Council on Family Relations. Her research focuses on health and social support in late life and includes studies of the health of rural older women, family relationships and caregiving, and elder abuse.
Tracy Robinson-Wood is a professor in the Department of Applied Psy- chology at Northeastern University. She is author ofThe Convergence of Race, Ethnicity, and Gender: Multiple Identities in Counseling. Thefifth edition, to be published by SAGE, is anticipated in 2016. Her research interests focus on the intersections of race, gender, sexuality, and class in psychosocial identity development. She has developed the Resistance Modality Inventory (RMI), which is a psychometrically valid measure of resistance, a theory she co-developed for black girls and women to optimally push back against rac- ism, sexism, classism, and other forms of oppression. Her research is also focused on parents’racial socialization messages within interracial families, and the relational, psychological, and physiological impact of microaggres- sions on highly educated racial, gender, and sexual minorities.
Amanda E. Sokan is an assistant professor (part-time) at University of Kentucky, Department of Health Management and Policy, in the College of
Public Health. She holds a Ph.D. in gerontology and masters in health administration from the University of Kentucky. Her research interests include elder rights and justice, elder abuse and mistreatment, LGBT aging, long-term care, aging and healthcare navigation, and health promotion.
Randy Thomas is a retired police officer having served for over 25 years in the law enforcement profession (Tampa Police Department, Richland County (SC) Sheriff’s Office and South Carolina Department of Public Safety). He was a member of the South Carolina Adult Protection Coordinating Council and was instrumental in the passage of South Carolina’s Omnibus Adult Protection Act. He received his bachelor’s degree from Chaminade University (1971) and his master’s degree in political science from the University of South Florida (Tampa 1974).
Amanda Weberis a doctoral student at Boston College in the department of Counseling Psychology. Her research interests include intersections of race, sexuality, gender and class as well as how trauma plays a role in people’s lives.
John T. White is the director of Professional and Community Development for Virginia Commonwealth University’s Department of Gerontology.
He received a BA in American history from Washington and Lee University, a Master of Science (gerontology) from Virginia Commonwealth University and is completing a doctorate in educational leadership. Previous chapters, articles, and presentations include LGBT and aging, operationalizing person-centered care and culture change, team building in long-term care and organizational diversity.
Foundations of Aging and
Sexual Identities
1
Theories, Constructs,
and Applications in Working
with LGBT Elders in Human Services
Debra A. Harley and Pamela B. Teaster
Abstract
This chapter presents an overview of select theories of sexual orientation and gender identity. Traditional theories of life span development offer a general framework within which to understand issues and experiences common to persons in later stages of life. The intent of this chapter is to discuss theoretical constructs and models of sexual identity, counseling, public health, gerontology, and social work that can be applied with aging LGBT populations. These theories underscore the necessity of helping present and future professionals who understand differences among LGBT elders and the complex nature of identity, their psychosocial adjustment, and ways in which stigma of sexual identity and gender identity affects their well-being. Although the various theories and models in this chapter are presented according to discipline, theories are not mutually exclusive to disciplines.
Keywords
LGBT theories
Sexual orientation identity development Genderidentity development
Life span development theoriesOverview
This introductory chapter on theories, constructs, and applications in working with LGBT elders presents an overview of select theories of sexual
orientation and gender identity. The reader is reminded that just as identities are culturally defined, theories of sexual identity are framed within cultural contexts as well. Thus, the ter- minology of the “LGBT” acronym may not accurately reflect how sexual minorities are dis- cussed within certain cultures. However, Burle- son (2005) nevertheless points out that “the sexual identity of bisexual, heterosexual, or homosexual is cultural; feelings of attraction are organic. People are hammered into molds, albeit their own culture’s mold, the world over”(p. 37).
Most of the models of sexual orientation and D.A. Harley (&)
University of Kentucky, Lexington, Kentucky, USA e-mail: [email protected]
P.B. Teaster
Virginia Tech, Blacksburg, VA, USA e-mail: [email protected]
©Springer International Publishing Switzerland 2016
D.A. Harley and P.B. Teaster (eds.),Handbook of LGBT Elders, DOI 10.1007/978-3-319-03623-6_1
3
gender identity are based on Eurocentric cultural models of sexuality. Traditional theories of life span development (e.g., Erikson1950; Levinson 1978, 1996) offer general frameworks within which to understand issues and experiences common to persons in later stages of life (Hash and Rogers2013).
Although it is beyond the scope of this chapter to include all theories, constructs, and applica- tions in human services, our intent is to present an overview of select theoretical constructs and models of sexual identity, counseling, public health, gerontology, and social work that can be applied with aging LGBT populations. These theories underscore the necessity of helping present and future professionals who understand differences among LGBT elders and the complex nature of identity, their psychosocial adjustment, and ways in which the stigma of sexual identity and gender identity affects their well-being.
Specific theories of late adulthood development and functional capacity are presented in Chap.3.
Also, it is not the intent of this chapter to present techniques for counseling LGBT elder in specific circumstances (e.g., couples or relationship, family, mental), nor to critique various theories.
Although the various theories and models in this chapter are presented according to discipline, theories are not mutually exclusive to disciplines.
A theory may easily be applied by various dis- ciplines to investigate and explain behavior and phenomenon.
Learning Objectives
By the end of the chapter, the reader should be able to:
1. Understand the various theories of LGBT identity development.
2. Identify the counseling theories that can be applied effectively for work with LGBT elders.
3. Identify the theories of public health and practice.
4. Identify the social work theories that work effectively with LGBT elders.
5. Explain how various practice models can be integrated in working with LGBT elders.
Introduction
Theory is a general statement, proposition, or hypothesis about a real situation that can be supported by evidence obtained through a sci- entific method. A theory explains in a proven way why something happens and offers guidance in explaining and responding to forgoing prob- lems (Gratwick et al. 2014). A construct is an idea, often referred to as a theory, which contains conceptual elements or parts that are put together in a logical order to explain something. Con- structs are typically subjective and not based on empirical evidence. A model is a blueprint for implementation. It describes what happens in practice in a general way. Theory and models are influenced by perspective, a value position (Payne 1997). Every discipline has theories to explain particular phenomena upon which it operate to guide development of hypotheses, research, and recommendations for best practices and policy. In fact, Payne suggests that theory succeeds best when it contains all three elements
—perspective, theory, and model/construct.
Theory serves the function of providing practi- tioners a guide for behavior in very specific cir- cumstances and making decisions.
Although various disciplines study aging, the study of older persons occurs primarily within the discipline of gerontology. Hooyman and Kiyak (2008) suggest that because of the multi- disciplinary nature of gerontology, examination of aging on the societal, psychosocial, and bio- logical levels. However, on all these levels, older sexual minorities (lesbian, gay, bisexual, trans- gender [LBGT]) have been relatively ignored in gerontological research (Grossman 2008; Orel 2004; Quam2004). Similarly, very little content
on specific care needs of LGBT persons exists in the nursing literature, especially for older adults.
This lack of focus is particularly troubling because nurses and other such caregivers are the front line of care and are in a position to create health care environments that will meet the needs of LGBT elders (Jablonski et al. 2013). In addition, many other disciplines omit LGBT populations from curricula and research to the extent that it appears that sexual minorities do not even exist (Hall and Fine2005; Harley et al.
2014). The lack of focus on LGBT elders in research and training programs frequently results in service providers who are inadequately to meet the needs of this population. According to Gratwick et al. (2014),“even when providers of aging services express willingness to become more responsive to the needs of LGBT older adults there is evidence that they do not take sufficient action” (p. 5). Hughes et al. (2011) report that of service providers affiliated with the National Association of Area Agencies on Aging, only 15 % provide services tailored to the need of older LGBT adults. Moreover, at the organizational level, LGBT older adults are lit- erally not being seen, organizations are not directing resources to these populations, and it appears that there is agency resistance to acknowledging the distinctiveness of LGBT aging issues.
Considering the increase in the number of older persons in general and the projection for continued growth in numbers and anticipated growth in the one to three million individuals in the USA over age 65 who are already identified as LGBT, the lack of focus of multidisciplinary research relegates older LGBT persons to a status of invisibility. Mabey (2011) contends that the omission of LGBT elders in gerontological research“leaves professional counselors without a substantive bridge with which to connect resources with treatment planning when working with sexual minorities”(p. 57). Moreover, age- ism as experienced in LGBT communities has
the additional impact of making a marginalized and stigmatized group feel even more of a minority.
Elderly LGBT Diversity, Identity, and Resilience
As an LGBT person and an older person, an LGBT elder does not belong to one homogenous group within the acronym. LGBT elders come from every race and ethnicity, nationality, gen- der, ability level, socioeconomic status, place, and space. Some LGBT elders have been married and have children, while other have either or neither. Thus, LGBT elders cannot be grouped or treated as one cohesive category (Mabey2011).
Older LGBT persons grew up during a time when homosexuality and gender nonconformity were viewed as a mental illness, a sin, or a sexual perversion. Open discussion about homosexual- ity, sexual identity, and gender identity was not done. Rather, secrecy about one’s sexual desires and behaviors was the norm; to reveal that one’s sexual orientation was other than heterosexual or one’s gender identity was other than conforming to social expectations was not only vocationally and socially devastating, but patently unsafe.
Negative attitudes and perceptions about LGBT persons are not only historical. Today, hetero- sexism, homophobia, transphobia, and biphobia continue to be intertwined in social customs, cultural beliefs, institutional structures, and pol- icy development. It is both the long-term and ongoing socially sanctioned discrimination, pre- judice, and stereotypes that present unique chal- lenges and, ironically, opportunities for LGBT persons globally (e.g., Austria, Canada, England, Ireland, USA). Because of the diversity among LGBT elders, some of the stereotypes encompass the entire LGBT population such as its attempts to covert heterosexuals that the population is composed of pedophiles or that it is a threat to marriage and structure of the family. Other
stereotypes are specific to subgroups of LGBT persons such as the belief that a lesbian cannot
“get a man,” gay men are responsible for HIV/AIDS, or that older LGBT persons are not attractive.
In a society that places an inordinate emphasis on youth, older adults face stigma and discrimi- nation beyond that of their younger counterparts, especially ageism (Butler 1994) in addition to lifelong negative attitudes and poor treatment related to their sexual orientation and gender identity. Hash and Rogers (2013) acknowledge
“while these difficult experiences can create a host of problems for LGBT individuals, they can also help them develop unique skill sets or strengths that their non-LGBT counterparts do not necessarily benefit from as they age” (p. 249). Further, Hash and Rogers suggest that despite difficulties associated with aging as LGBT persons, elders have successfully devel- oped social networks, successfully developed a strong sense of identity through the coming-out process, and have successfully responded to discrimination and stigma to develop a positive sense of self and identity leading to stronger ego integrity. Despite the challenging and threatening context often associated with LGBT elders’ear- lier lives, most are now comfortable with their sexual orientation and gender identity and dis- play a marked resilience to the minority stress they experienced in their lives (Irish Association of Social Workers 2011; Szymanski and Gupta 2009) (see especially Chaps. 6, 7, 8 and 10 in this book on resilience among LGBT elders of color).
The process of aging for LGBT persons pre- sents the typical challenges and concerns related to health status, financial stability, loss of a spouse or partner, and so forth. We present the case of Maria, a Latina 73-year-old lesbian, to illustrate some of the challenges she faces.
As a member of the Latino culture Maria believes that the Latino community is less accepting of homosexuality. Maria recognizes that living in Los Angeles she faces the challenges of being invisible because of ageism, an LGBT community that
values youth, and rejection of old persons. In addition, cultural barriers and being very self-reliant further isolate Latinos LGBT elders. In a needs assessment of older Hispanic LGBT adults, participants expressed varied experiences of aging as: (a) not different from that of the general population, with more self-acceptance, particularly if one isfinancially secure, (b) there is a great deal of rejection of older persons because they are persons in which people are not interested and, even why they do not have a support group even among themselves, (c) social isolation within their own families because of their identities as LGBT people, and (d) dual discrimination as Latinos and as members of the LGBT community (www.
gallup/poll/158066/special-report-adults-identity- lgbt.aspx).
Case of Maria
Maria is a Latina 73-year-old lesbian. She and her partner of 40 years live in a small third floor apartment in Los Angles. The building is old and does not have an ele- vator. Maria has arthritis in her knees and hands, hypertension, and glaucoma. Here partner, Sophia, is in better health but has asthma. Neither Maria nor Sophia has children and both have been estranged from their families for most of their adult life. They consider themselves “closeted” and have identified themselves publically as sisters.
Maria worked for 55 years as a house- keeper for a wealthy family. She does not have retirement income and receives Social Security of $540 per month, Medicare, and food stamps. Sophia worked as a city bus driver for 30 years and receives retirement benefits, Social Security, and Medicare.
The two of them are concerned about the feasibility of continuing to live in their apartment, but know that it will be difficult to find other affordable housing. In addi- tion, their share of cost for health care continues to increase. Although neither women have been diagnosed with depres- sion, both express having feelings of depression.
Questions
What identity issues are confronting these two women?
Do they have a social network? How can they form a social network?
Can you identify resilience factors for Maria and Sophia?
What type of service would benefit Maria and Sophia?
As previously mentioned, the theories of Erikson (1950) and Levinson (1978,1996) have foundational significance in explaining the psy- chological development of LGBT elders. In Erikson’s final stage of psychosocial develop- ment,Ego Integrity v. Despair, older adults (age 60 and over) reflect upon and evaluate their lives.
When confronted with loss, the older person must arrive at acceptance of his or her life or will fall into despair. The ability to accept one’s life and self in the ego integrity stage may be more complicated for LGBT elders (Hash and Rogers 2013; Humphreys and Quam 1998). According to Humphreys and Quam, the social stigma experienced by LGBT elders can adversely affect how they view their identity and life. Despair can be influenced by the culmination of losses over a lifetime. Transgender persons may be at a greater risk for despair because of the indignity they face from society and lack of support from loved ones. Moreover, older LGBT adults may have struggled with development as reflected in earlier stages of Erikson’s theory, which could impact developmental tasks during thefinal stage. Lev- inson’s theories of life span development exam- ine primary pattern of people’s lives at particular points in time and the transitions necessary between eras in life for them to successfully develop into adulthood. Similar to Erikson, Levinson identifies the final era as older adult- hood (age 60 and over). This era often involves significant adjustment to a significant change and acceptance of immortality. For LGBT elders, this late stage life transition may involve acceptance
and openness about sexual orientation and gen- der identity (Humphreys and Quam).
The remainder of this chapter concerns select theories and models used in the disciplines of counseling, public health, and selected social sciences. Sexual identity theories are also pre- sented. As mentioned earlier, theories are not discipline specific; however, some disciplines may gravitate more toward certain theories and models.
Theories and Constructs on Sexual Identity
An introduction to theories of sexual identity must at least mention the work of Sigmund Freud (1949). According to Freud, homosexuality and bisexuality resulted from unresolved conflicts (fixation) occurring within one of the stages of psychosexual development. In addition, Freud hypothesized that all human beings are innately bisexual and it is the influence of family and environment that determines if one becomes homosexual or heterosexual. However, Freud never identified homosexuality or bisexuality as a mental disorder. Freud’s theory is not empiri- cally tested and is not used today in discussion of sexual identity formation.
Later, the work of Erving Goffman (1963), Stigma: Notes on the Management of Spoiled Identity, was one of the most important early works addressing minority self-identity (Eliason and Schope2007). According to Goffman, social stigma is learned and internalized through childhood socialization and shapes the minority person’s identity. The minority person shares the belief of the majority if it deems that he or she is a failure and abnormal. This belief leads to self-hate and self-derogation. Goffman proposed that formation of the minority sexual identity involves dealing with social expectations of what is considered normal. Conversely, Altman (1971) and Plummer (1973) offered explanations for the development of a stable “homosexual identity” (Eliason and Schope 2007). Altman suggested
that self-disclosure of one’s homosexuality was beneficial because coming-out meant dealing with the socially learned “internalization of oppression,” which is liberating. Plummer’s approach was one of individuals adopting a
“homosexual way of life”or a “career type” of sexuality. Recognizing homosexuality as a social construct developed by the majority to restrict and pathologize a sexual minority, Plummer argued that all forms of deviancy need to be viewed within a historical and cultural context.
He regarded current social hostility to homo- sexuality as responsible for many of what he labeled“pathologies.” Plummer was one of the first theorists to present identifiable stages of
“homosexual identity” (see Table 1.1) (Eliason and Schope).
Subsequent to Altman (1971) and Plummer’s (1973) theories, an abundance of stage models on sexual identity formation evolved, the majority of which moved away from the deviance model to a focus on healthy consequences of accepting one’s sexuality (see Table 1.2). Eliason and Schope (2007) identify two assumptions about stage model theorists. First, most assumed that one is or is not gay or lesbian and embraced the argument from an Essentialists’ perspective.
Second, most models are based on a review of the literature and are not empirically tested or are based on single case or small sample size.
Probably, one of the most influential and frequently cited theories of gay and lesbian identity development is that of Cass (1979). Cass
describes a process of six stages of gay and lesbian development. Although these stages are sequential, some persons revisit stages at differ- ent points in their life. Each stage is accompa- nied by a task. Cass believes that coming-out is a lifelong process of exploring one’s sexual ori- entation and lesbian or gay identity and sharing it with others. Table1.3contains Cass’s model of identity formation.
Bisexual Identity Formation. Though limited research as been conducted on development of bisexual identity formation, probably the most important research on bisexuality was that of Alfred Kinsey with the publication of Sexual Behavior in the Human Male (Kinsey et al.
1948) and Sexual Behavior in the Human Female (Kinsey et al.1953) (as cited by Burle- son2005). Kinsey developed the Kinsey scale, in which individuals can fall anywhere along a continuum of 0 (exclusively heterosexual) and 6 (exclusively homosexual). Burleson contends that Kinsey had created the present model of bisexuality without ever once using the word bisexual. In addition, Kinsey scale clarified two issues: (a) There is great variability of sexual orientation, and (b) an implication that perhaps all human beings on this continuum are ranked the same way (i.e., heterosexuality is not primary or held above other sexual orientations). Kin- sey’s work, while groundbreaking, was rudi- mentary and did not address the complexities of behavior and attraction and past behavior and future predictions. In response to questions of complexity, Fritz (1993) expanded on Kinsey’s continuum model to measure a person’s past and future sexual attraction, behavior, fantasies, emotional preference, social preference, lifestyle, and self-identification.
Stroms (1978) offers yet different model of sexual attraction, a multiple-variable model, in which sexual attraction to different genders is examined independently of each other. In this model, Stroms’scale has one end representing no attraction to one gender and the other end pre- senting high attraction to that gender. The con- tinuum offers great variation within this model.
Although this model did not include transgender persons, a scale could be created for them. In Table 1.1 Plummer’s stages of homosexual identity
Stage 1: Sensitization—thinks about one’s sexual identity
Stage 2: Significance and disorientation—accepts the deviant label with all the potential social consequences.
Social oppression creates disequilibrium where the homosexual person becomes stalled, perhaps for life, in this stage
Step 3: Coming-out—goes public with one’s rebuilt sexual identity. Disclosure is linked to the person’s willingness and ability to join the homosexual community
Stage 4: Stabilization—no longer questions one’s homosexual identity
Adapted from Plummer (1973)
Table 1.2 Stage theories of sexual identity formation
Theorists Population Stages of identity formation
Ponse (1978) Lesbian “Gay trajectory”
Subjective feelings of difference from sexual/emotional desire for women Understanding feelings as lesbian Assuming a lesbian identity Seeking company of lesbians
Engaging in lesbian relationship (sexual and/or emotional)
aColeman (1982) Precoming-out
Coming-out Tolerance Acceptance Pride Integration
Minton and McDonald (1984) Gay men Egocentric
Sociocentric Universalistic
aFaderman (1984) Lesbian Critical evaluation of societal norms and acceptance of lesbian identity
Encounters with stigma
Lesbian sexual experience (optional)
Sophie (1985/1986) Lesbian First awareness
Testing/exploration Acceptance Integration
Chapman and Brannock (1987) Lesbian Same-sex orientation Incongruence Self-questioning Choice of lifestyle
Troiden (1988) Men Spirals rather than linear
Sensitization Confusion Assumption Commitment
aMorales (1989) Racial/ethnic
minority LGB
Denial of conflicts
Bisexual versus gay/lesbian identity Conflicts in allegiances
Establish priorities in allegiances Integrate various communities
aReynolds and Pope (1991) Multiple identity formation
Passive acceptance of society’s expectations for one aspect of self
Conscious identification with one aspect of self Segmented identification with multiple aspects of self
Intersection identities with multiple aspects of self
aIsaacs and McKendrick (1992) Gay men Identity diffusion Identity challenge Identity exploration Identity achievement Identity commitment Identity consolidation
(continued)
addition, Strom’s model includes people who tend toward asexuality. The model describes attraction to women and men as two separate variables (Burleson2005).
Theoretical State Stage Models. In the USA, the 1970s ushered in a new era of research about
sexual orientation identity development with the emergence of theoretical state stage models. The primary focus of these models was on the resolu- tion of internal conflict related to identification as lesbian or gay and informed the “coming-out” process. Bilodeau and Renn (2005) describe these Table 1.2 (continued)
Theorists Population Stages of identity formation
aSiegel and Lowe (1994) Gay men Turning point
Aware of difference Identify source of difference Coming-out
Assumption Acceptance Celebration Maturing phase Reevaluation Renewal Mentoring
aFox (1995) Bisexual First opposite-sex attractions, behaviors,
relationships
First same-sex attractions, behaviors, relationships First self-identification as bisexual
Self-disclosure as bisexual McCarn and Fassinger (1997); Fassinger
and Miller (1996)
Lesbian and gay Awareness Exploration
Deepening/commitment Internalization/synthesis
aEliason (1996) Lesbian Cycles/not linear
Pre-identity Emerging identity
Recognition/experiences with oppression Reevaluation/evolution of identities
aNutterbrock et al. (2002) Transgender Awareness Performance Congruence Support
aDevor (2004) Transgender Abiding anxiety
Confusion
Comparison (birth sex/gender) Discover trans identity Confusion (trans) Comparison (trans) Tolerance (trans) Delay before acceptance Acceptance
Delay before transition Transition
Acceptance of post-transition gender/sex Integration
Pride Adapted from Eliason and Schope (2007)
aNo empirical validation
models as having the following characteristics:
(a) begin with a stage, (b) describe individuals using multiple defense strategies to deny recog- nition of personal homosexual feelings, (c) include a gradual recognition and tentative acceptance, (d) have a period of emotional and behavioral experimentation with homosexuality, (e) involve a time of identity crisis, and (f) marked by the coming-out process. Although difference exists among the stage models, which illustrate the difficulty of using one model to understand the complex psychosocial process of the development of sexual orientation identity, their predominance and persistence in the research literature and in current educational practice suggest that they represent with some accuracy the developmental process (Bilodeau and Renn2005).
The minority stress model (Brooks 1981;
Meyer1995) is useful in understanding aspects
of sexual minority identity development for older LGBT adults and the impact of sociocultural issues on their lives. Based on this model, indi- viduals in minority groups experience additional minority-related stressors that individuals who are part of the majority do not have to contend.
The minority stress model is a consolidation of several theories and models that propose that minority persons experience chronic stressors and these stressors can lead to negative psycho- social adjustment outcomes. According to Meyer (2010), the minority stress model does not attempt to imply that sexual minorities have higher rates of psychosocial issues because of their sexual orientation and gender identity;
rather, the model identifies the pathogenic con- ditions that stigmatize LGBT persons and treat them as inferior to heterosexual individuals.
Minority stressors for LGBT persons include Table 1.3 Cass model of gay and lesbian identity formation
Stage 1 Identity Confusion—Personalization of information regarding sexuality.“Could I be gay?”This stage begins with the person’sfirst awareness of gay or lesbian thoughts, feelings, and attractions. The person typically feels confused and experience turmoil
Task Who am I?—Accept, deny, reject
Stage 2 Identity Comparison—Accepts possibility one might be homosexual.“Maybe this does apply to me.” In this stage, the person accepts the possibility of being gay or lesbian and examines the wider implications of that tentative commitment. Self-alienation becomes isolation
Task Deal with social alienation
Stage 3 Identity Tolerance—Accepts probability of being homosexual and recognizes sexual/social/emotional needs of being homosexual.“I am not the only one.”The person acknowledges that she or he is likely lesbian or gay and seeks out the other lesbian and gay people to combat feelings of isolation. There is increased commitment to being lesbian or gay
Task Decrease social alienation by seeking out lesbian and gay persons
Stage 4 Identity Acceptance—Accepts (versus tolerates) homosexual self-image and has increased contact with lesbian/gay subculture and less with heterosexual.“I will be okay.”The person attaches positive connotation to her or his lesbian or gay identity and accepts rather than tolerates it. There is continuing and increased contact with the lesbian and gay culture.
Task Deal with inner tension of no longer subscribing to society’s norm, attempt to bring congruence between private and public view of self
Stage 5 Identity Pride—Immersed in lesbian/gay subculture, less interaction with heterosexuals. Views world divided as“gay”or“not gay.” “I’ve got to let people know who I am!”There is confrontation with heterosexual establishment and disclosure to family, friends, coworkers, etc
Task Deal with incongruent views of heterosexuals
Stage 6 Identity Synthesis—Lesbian or gay identity is integrated with other aspects of self, and sexual orientation becomes only one aspect of self rather than the entire identity
Task Integrate lesbian and gay identity so that instead of being the identity, it is an aspect of self Adapted from Cass (1979)
experiences of discrimination, concealment or disclosure of sexual orientation/gender identity, expectations of prejudice and discrimination, and internalized homonegativity (Cox et al. 2011;
Meyer2003). Unlike ethnic and racial minority groups who experience minority stress, LGBT persons who experience sexual minority stress often do not receive support and understanding from their families of origin (Dziengel 2008).
Minority stress in LGBT persons has been linked to higher levels of depression and negative health outcomes (Cox et al.2009; Huebner and Davis 2007).
McCarn-Fassinger (1996) developed the les- bian identity development model, and Fassinger and Miller (1996) later validated the applicability of the theory with gay men (subsequently refer- enced in the literature as Fassinger’s gay and lesbian identity development model), which examines identity development from a personal and a group perspective. The lesbian identity development model includes four phases:
awareness, exploration, deepening/commitment, and internalization/synthesis. The use of “pha- ses”is intentional to explicitly indicateflexibility that individuals revisit earlier phases in new or different contexts. The model explores attitudes of lesbians and gay men toward self, other sexual minorities and gender identity, and heterosexu- als. A distinguishing aspect of Fassinger’s model is that lesbians, gays, or bisexuals are not required to“come out”or to be actively involved in the lesbian, gay, or bisexual community.
A life span approach to sexual orientation development has been introduced an alternative to stage models. D’Augelli (1994) offers a “life span”model of sexual orientation development.
This model takes social contexts into account in different ways than stage models. In addition, D’Augelli’s model has the potential to represent a wider range of experiences than do the theories relating to specific racial, ethnic, or gender groups and addresses issues often ignored in other models. D’Augelli presents human devel- opment as unfolding in concurring and multiple paths, including the development of a person’s self-concept, relationships with family, and con- nections to peer groups and community. This
model suggests that sexual orientation may be fluid at certain times and morefixed at others and that human growth is intimately connected to and influenced by both biological and environmental factors. D’Augelli’s model has six “identity processes” that function more or less indepen- dently and are not sequenced in stages (see Table 1.4). An individual may experience development in one process to a greater extent than another, and, depending on context and timing, he or she may be at different points of development in a given process (Bilodeau and Reen2005).
Renn and Bilodeau (2005) extended D’Aug- elli’s (1994) model and applied it to under- standing corresponding processes in the formation of transgender identity development.
Bilodeau (2005) found that transgender persons describe their gender identities in ways that reflect the six processes of D’Augelli’s model.
Since the inclusion of gender identity disorder (GID) for the first time in the diagnostic and statistical manual of mental disorders (DSM) in 1980 as a mental illness, other theories on transgender identity formation have been pro- posed by Nutterbrock et al. (2002) and Devor (2004), bisexual identity formation by Fox (1995), and multiple identity formation by Rey- nolds and Pope (1991) (Table 1.2); however, none of these models have been empirically validated. In the fifth edition of the DSM, GID was deleted and replaced with gender dysphoria (GD), indicating that it is not a mental illness, rather a lifestyle with which individuals may need assistance in making adjustments. Feminist, postmodern, and queer theoretical theorists (e.g., Butler1990, 1993; Creed1995; Feinberg 1996, Table 1.4 D’Augelli life span model of sexual orienta- tion development
Exiting homosexuality
Developing a personal LGB identity Developing an LGB social identity Becoming an LGB offspring Developing an LGB intimacy status Entering an LGB community D’Augelli (1994)
1998; Halberstam 1998; Wilchins 2002) have introduced alternatives to medical and psychiat- ric perspectives on gender identity. These theo- rists suggest that gender is not necessarily linked to biological sex assignment at birth, but is cre- ated through complex social inequities, and gender identity is more fluid. These theorists propose transgender identities and genderfluidity as normative as oppose to the binary, two-gender system and the influence of themes reflecting fluidity of gender that have emerged in the dis- cipline of human development (Bilodeau and Renn2005).
As an extension of sexual minority identity, in 2004 Lev introduced the transgender emergence model, a stage model that examines at how transgender people come to understand their identity. Lev’s model comes from the perspective of a counseling or therapeutic point of view and focuses on what the individual is experiencing and the responsibility of the counselor or inter- ventionist. As with other stage theories, Lev’s model begins with thefirst stage as awareness.
(see Table 1.5 for Lev’s stages). Lev’s clinical and philosophical ideology is based on the belief that transgenderism is a normal and potentially healthy variation of human expression. As pos- tulated by Goldner (1988), gender dichotomies are not only restrictive, but also constitutive, with the gendering of social spheres constraining personal freedom and gender categories
determining what is possible to know. Lev’s approach is to consider the ecosystem (i.e., influence of environment on perception and behavior) in working with transgender persons.
According to Lev, “gender variance does not simply live within individuals but exists‘within’ a larger matrix of relationships, families, and communities”(p. xx).
Lev offers three goals for therapists working with transgendered persons and their families. The first goal is “to accept that transgenderism is a normal expression of human potentiality.” The second goal is“to place transgenderism within a larger social context that includes an overview of the existence of gender variance throughout his- tory.”The third goal is“to outline various etiolog- ical theories that impact assessment and diagnosis, as well as innovative, possibly iconoclastic treat- ment strategies to work with gender-dysphoric, gender-variant, transgendered, third-sexed, trans- sexual, and intersexed people as members of extended family systems”(pp. xx–xxi).
Counseling Theories and Practice for Older Adults
A commonly held view of older persons is that they are mentally incompetent. Although there is some cognitive decline associated with normal aging, the majority of older adults do not Table 1.5 Lev’s transgender emergence model
Stage 1 Awareness—Gender-variant people are often in great distress. The therapeutic task is the normalization of the experiences involved in emerging as transgender
Stage 2 Seeking Information/Reaching Out—Gender-variant people seek to gain education and support about transgenderism. The therapeutic task is to facilitate linkages and encourage outreach
Stage 3 Disclosure to Significant Other—Involves the disclosure of transgenderism to significant other. The therapeutic task involves supporting the transgendered person’s integration in the family system Stage 4 Exploration (Identity and Self-Labeling)—Involves the exploration of various (transgender) identities.
The therapeutic task is to support the articulation and comfort with one’s gendered identity Stage 5 Exploration (Transition Issues and Possible Body Modification)—Involves exploring options for
transition regarding identity, presentation, and body modification. The therapeutic task is the resolution of the decision and advocacy toward their manifestation
Stage 6 Integration (Acceptance and Post-Transition Issues)—The gender-variant person is able to integrate and synthesis (transgender) identity. The therapeutic task is to support adaptation to transition-related issues
Adapted from Lev (2004)
